The Hospital of Tomorrow Case Study: Multidisciplinarity, Inclusiveness and Holistic Approaches to Foster Innovation in Complex Organizations.

BACKGROUND: This case study describes and analyses an action research initiative undertaken by management, staff and WHO at the St. Orsola-Malpighi Polyclinic in Bologna, Italy. The initiative utilised staff engagement approaches developed during the COVID-19 pandemic to rethink and reshape future development plans. The initiative provides a 'how-to' case study for complex health facilities on ways to create similar multisectoral, inclusive and holistic processes in planning structural, functional and organizational solutions for their 'hospitals of tomorrow'. METHODS: The case study utilised an action research approach coordinated by a team of WHO facilitators in close collaboration with the Board of Hospital Directors. Heterogeneous and multidisciplinary working groups were created, with members from different levels of the hospital staff. In the context of facilitated group meetings held weekly over a one-year period, participants were asked to review topics of interest to future plans of the hospital and make recommendations on effective/innovative ways of addressing these in the short and long term. Working groups focused on different challenges. RESULTS: The initiative was successful in creating and sustaining broad staff engagement in the future planning processes. 80% groups maintained high staff participation throughout the entire project year. Participating staff reported enhanced communication and cooperation between departments represented in different groups. 87% of the proposed plans suggested by the working groups were approved by the Board for implementation. CONCLUSION: Key factors contributing to the high approval rate of plans, strong engagement record of staff and enhanced cooperation between involved departments; included: multisectoral/cross hierarchal staff involvement, group attention to defining time-bound contextual goals, flexible implementation monitoring approaches, personnel skills and profiles of participants, direct and open communication at all levels and times, member commitment and clear exit strategy. The case study is presented as a model to stimulate similar actions in other complex health care facilities.

Symptoms of depression, anxiety, and thoughts of suicide/self-injury in adolescents and young adults living with HIV in Botswana.

Globally, mental health problems have been reported to be more common in youth living with HIV (YLWH) than in the general population, but routine mental health screening is rarely done in high-volume HIV clinics. In 2019, YLWH in a large HIV clinic in Botswana were screened using the Generalized Anxiety Scale-7 (GAD-7) and Patient Health Questionnaire-9 (PHQ-9) in a pilot standard-of-care screening programme. Two-way ANOVA was used to describe the effects of age group (12-<16, 16-<20 and 20-25 years old) and sex on GAD-7 and PHQ-9 scores. Chi-square statistics were used to compare characteristics of YLWH with and without potential suicidality/self-harm symptoms based on question 9 in the PHQ-9. Among 1 469 YLWH, 33.1%, 44.3% and 15.0% had anxiety, depression and potential suicidality/self-harm symptoms respectively. YLWH of 20-25 years old and 16-<20 years old had higher GAD-7 scores compared to 12-<16-year-olds (p = 0.014 and p = <0.001 respectively). Female YLWH of 20-25 years old had higher PHQ-9 scores compared to 12-<16-year-olds (p = 0.002). There were no other sex-age dynamics that were statistically significant. Female YLWH endorsed more thoughts of suicidality/self-harm than males (17% versus 13%, p = 0.03 respectively). Given the proportion of YLWH with mental health symptoms, Botswana should enhance investments in mental health services for YLWH, especially for young female adults who bear a disproportionate burden.

Investing in preparedness for rapid detection and control of epidemics: analysis of health system reforms and their effect on 2021 Ebola virus disease epidemic response in Guinea.

The 2014-2016 West Africa Ebola Virus Disease (EVD) Epidemic devastated Guinea's health system and constituted a public health emergency of international concern. Following the crisis, Guinea invested in the establishment of basic health system reforms and crucial legal instruments for strengthening national health security in line with the WHO's recommendations for ensuring better preparedness for (and, therefore, a response to) health emergencies. The investments included the scaling up of Integrated Disease Surveillance and Response; Joint External Evaluation of International Health Regulation capacities; National Action Plan for Health Security; Simulation Exercises; One Health platforms; creation of decentralised structures such as regional and prefectural Emergency Operation Centres; Risk assessment and hazard identification; Expanding human resources capacity; Early Warning Alert System and community preparedness. These investments were tested in the subsequent 2021 EVD outbreak and other epidemics. In this case, there was a timely declaration and response to the 2021 EVD epidemic, a lower-case burden and mortality rate, a shorter duration of the epidemic and a significant reduction in the cost of the response. Similarly, there was timely detection, response and containment of other epidemics including Lassa fever and Marburg virus disease. Findings suggest the utility of the preparedness activities for the early detection and efficient containment of outbreaks, which, therefore, underlines the need for all countries at risk of infectious disease epidemics to invest in similar reforms. Doing so promises to be not only cost-effective but also lifesaving.

Standardized Definitions of In Utero Human Immunodeficiency Virus and Antiretroviral Drug Exposure Among Children.

In countries with high human immunodeficiency virus (HIV) prevalence, up to 30% of pregnant women are living with HIV, with fetal exposure to both HIV and antiretroviral therapy during pregnancy. In addition, pregnant women without HIV but at high risk of HIV acquisition are increasingly receiving HIV preexposure antiretroviral prophylaxis (PrEP). Investments are being made to establish and follow cohorts of children to evaluate the long-term effects of in utero HIV and antiretroviral exposure. Agreement on a key set of definitions for relevant exposures and outcomes is important both for interpreting individual study results and for comparisons across cohorts. Harmonized definitions of in utero HIV and antiretroviral drug (maternal treatment or PrEP) exposure will also facilitate improved classification of these exposures in future observational studies and clinical trials. The proposed definitions offer a uniform approach to facilitate the consistent description and estimation of effects of HIV and antiretroviral exposures on key child health outcomes.

Isoniazid Preventative Therapy uptake for child household contacts of tuberculosis index cases, Kisumu County, Kenya, 2014-2015.

Isoniazid Preventative Therapy (IPT) is recommended for children aged less than 5 years that have been in contact with an open case of TB, and screen negative for TB, to prevent the risk of TB progression. We examined IPT uptake among child household contacts of TB index cases, within a TB case detection study, in a high TB burden region. A cross-sectional study involving all IPT-eligible children drawn from a TB case detection study was done in Kisumu County, Kenya between 2014 and 2015. By linking a subset of the study database to the TB program IPT register, we described Child contacts as initiated on IPT and TB index cases as having child contacts initiated on IPT based on whether their names or their child contacts names respectively, were found in the IPT register. Logistic regression analysis was used to describe index and contact characteristics associated with IPT initiation. Of 555 TB index cases recruited into the study, 243 (44%) had a total of 337 IPT-eligible child contacts. Forty-seven (19%) index cases that had child contacts initiated on IPT; they were more likely to have been diagnosed with smear positive TB compared to those who were diagnosed with smear negative TB (OR 5.1, 95%CI 1.1-23.2; P=0.03) and to reside in rural Kisumu compared to those in urban Kisumu (OR 3.3, 95% CI 1.6-6.8; P<0.01). The 51 (15%) child contacts that were initiated on IPT were more likely to be were first degree relatives of the index case compared to those who were not (OR 2.6, 95% CI 1.2-5.5; P=0.02) and to reside in rural Kisumu compared to those in urban Kisumu (OR 2.6, 95% CI 1.2-5.1; P<0.01). IPT initiation, which is influenced by index and contact characteristics, is suboptimal. The TB program should provide health worker training, avail appropriate pediatric TB diagnostic tools, job aids and monitoring tools, and ensure continuous supply of medication, and to facilitate IPT implementation. Additionally, targeted health education interventions should be formulated to reach those who are unlikely to accept IPT.

Ethically providing Routine HIV testing services to bereaved populations.

BACKGROUND:: The delivery of public health policies may be in conflict with individualism. OBJECTIVES:: To propose measures to ethically provide routine HIV testing services to persons visiting a funeral home. RESEARCH DESIGN:: A document analysis of study documents and presentations made to an institutional review board. PARTICIPANTS AND RESEARCH CONTEXT:: Institutional review board members (both lay and professionals) and Study investigators attending an `open session' where study investigators were invited to elaborate on some study procedures. ETHICAL CONSIDERATIONS:: Identities of all parties were anonymized. FINDINGS:: Opt-out approaches to HIV testing, grief counseling, relational ethics, and a modular consenting process were proposed to safeguard clients' autonomy. The golden-rule approach and protective empowering were suggested to protect clientele beneficence. DISCUSSION AND CONCLUSION:: It is possible to ethically provide universal HIV testing and counseling services among grieving populations in this setting; elsewhere, this should be contextualized.

Isoniazid preventative therapy uptake for child household contacts of tuberculosis index cases, Kisumu County, Kenya, 2014-2015

Isoniazid Preventative Therapy (IPT) is recommended for children aged less than 5 years that have been in contact with an open case of TB, and screen negative for TB, to prevent the risk of TB progression. We examined IPT uptake among child household contacts of TB index cases, within a TB case detection study, in a high TB burden region. A cross-sectional study involving all IPT-eligible children drawn from a TB case detection study was done in Kisumu County, Kenya between 2014 and 2015. By linking a subset of the study database to the TB program IPT register, we described Child contacts as initiated on IPT and TB index cases as having child contacts initiated on IPT based on whether their names or their child contacts names respectively, were found in the IPT register. Logistic regression analysis was used to describe index and contact characteristics associated with IPT initiation. Of 555 TB index cases recruited into the study, 243 (44%) had a total of 337 IPT-eligible child contacts. Forty-seven (19%) index cases that had child contacts initiated on IPT; they were more likely to have been diagnosed with smear positive TB compared to those who were diagnosed with smear negative TB (OR 5.1, 95%CI 1.1-23.2; P=0.03) and to reside in rural Kisumu compared to those in urban Kisumu (OR 3.3, 95% CI 1.6-6.8; P<0.01). The 51 (15%) child contacts that were initiated on IPT were more likely to be were first degree relatives of the index case compared to those who were not (OR 2.6, 95% CI 1.2-5.5; P=0.02) and to reside in rural Kisumu compared to those in urban Kisumu (OR 2.6, 95% CI 1.2-5.1; P<0.01). IPT initiation, which is influenced by index and contact characteristics, is suboptimal. The TB program should provide health worker training, avail appropriate pediatric TB diagnostic tools, job aids and monitoring tools, and ensure continuous supply of medication, and to facilitate IPT implementation. Additionally, targeted health education interventions should be formulated to reach those who are unlikely to accept IPT

Human Immunodeficiency Virus and Hepatitis B Virus Infection Prevention Following Occupational Exposure among Staff at a Regional Referral Hospital in Western Kenya.

BACKGROUND: Postexposure prophylaxis (PEP) with antiretroviral therapy (ART) and vaccination against hepatitis B virus (HBV) aides in preventing human immunodeficiency virus (HIV) infection and HBV, respectively, from accidental or occupational exposure. We assessed compliance to guidelines for HIV and HBV prevention after occupational exposure among hospital staff at a referral Kenyan hospital. METHODS: We reviewed PEP registers for hospital staff reporting an occupational injury at a referral hospital in Western Kenya between January 2011 and December 2012. Proportions were used to summarize number of participants receiving the recommended services, Kaplan-Meier curves were used to describe time to ART initiation, and Chi-square statistics was used to describe the association between participant characteristics and PEP completion rates. P < 0.05 was considered statistically significant. RESULTS: Majority of documented hospital staff (n = 52) were health workers (63%) and students (27%) and had high HIV risk exposures (97%). All had timely PEP initiation with 50% completing PEP. Completion rates did not vary by gender (P = 0.78), exposure type (P = 1.0), or department of exposure (P = 0.75). Retesting for HIV and negativity rates at months 1.5, 3, and 6 were 96%, 25%, and 17% and 100%, 100%, and 100%, respectively. At the time of exposure, 17% (9) of staff were HBV vaccinated and HBV status of sources was unknown; no intervention was provided for HBV prevention. CONCLUSIONS: Low rates of completion and follow-up negate intended benefits of PEP. Efforts should be directed to enforce universal precaution practices and completion of PEP. Low rates of HBV testing and vaccination illustrate the need for support for the implementation of HBV prevention guidelines.

The Use of Laypersons to Support Tuberculosis Screening at a Kenyan Referral Hospital.

BACKGROUND: The former Nyanza Province of Kenya bore the brunt of HIV-driven tuberculosis (TB); 62% of the 19,152 cases in 2010 were HIV co-infected. The use of laypersons to improve TB case finding in community settings has shown rewarding results in other countries. We have no documented Kenyan experience in health facility settings. We evaluated the benefit of using laypersons to support TB screening and referrals at the former Nyanza Province of kenya province's largest regional referral facility. METHODS: In 2010, five high school graduates were trained on symptomatic recognition of TB suspects and assisted sputum production by the region's District's TB and Leprosy Coordinator. They then identified and referred TB suspects (from hospital patients and visitors) at waiting-areas and wards to clinicians and documented their TB screening and referral outcomes. We describe results from one waiting-area with complete documentation between January and December 2011. RESULTS: Of the 217 TB suspects identified, majority were male (55%); their median age was 36 (range 1-70) years. 11% (23) were aged <15 years; 65% (15) were diagnosed with TB by, a combination of sputum microscopy and chest X-rays (5) followed by chest X-ray alone (50), then sputum microscopy alone (1), and TB score chart (4). Of those aged 15+ years, 72% (140) were diagnosed with TB by a combination of sputum microscopy and chest X-rays (75) followed by sputum microscopy alone (38), and chest X-ray alone (27). Excluding cases that transferred out, this process contributed to 33% of Jaramogi Oginga Odinga Teaching and Referral Hospital's annual TB case burden. CONCLUSIONS: TB case detection in high TB burden regions can be supported the use of laypersons in hospital settings.

Victims and Perpetrators of Intimate Partner Violence Among Sexually Active Youth in a Community With a High HIV Prevalence in Western Kenya.

BACKGROUND: Physical intimate partner violence (IPV) is an important risk factor for sexually transmitted infections, including HIV. We set out to determine the prevalence and correlates of IPV among youth aged 15 to 24 years - in a community with a high HIV prevalence - with a view to recommending strategies to address IPV. METHODS: We analysed data from an HIV seroprevalence survey, which included participants aged 13 years and above and was conducted between November 2012 and December 2014 in Gem Subcounty, Siaya County, Western Kenya. Participants between 15 and 24 years old (youth) were described as "perpetrators of IPV" if they had done anything to physically hurt their sexual partners in the previous year and as "victims of IPV" if they had been physically hurt by a sexual partner in the same timeframe. Logistic regression was used to determine factors associated with being either a victim or perpetrator of IPV. RESULTS: Of 1,957 participants included in the analysis, 142 (7%) were victims of IPV, and 77 (4%) were perpetrators of IPV. Victims were likely to be women (adjusted odds ratio [AOR] 7.9; 95% CI, 3.6 to 17.5), in a relationship or married (AOR 3.1; 95% CI, 1.8 to 5.4), and to have had multiple lifetime sexual partners. Victims of IPV were also more likely than not to have been subjected to sexual violence in the past (AOR 1.9; 95% CI, 1.0 to 3.4) or recently (AOR 3.9; 95% CI, 2.2 to 6.8). Perpetrators were likely to be men (AOR 2.1; 95% CI, 1.2 to 3.7), with 5 or more lifetime sexual partners (AOR 2.8; 95% CI, 1.3 to 6.3), and to have committed sexual violence recently (AOR 2.9; 95% CI, 1.1 to 7.7). CONCLUSION: There was a high prevalence of IPV among sexually active youth in this rural community. Study participants were recurrent victims or perpetrators and reported behaviours that put them at risk of HIV acquisition. Health programmes should screen for IPV victims and perpetrators using identified characteristics. Existing policies regarding gender-based violence should be enforced, and future research should focus on the impact of IPV prevention programmes.

Performance of Clinical Screening Algorithms for Tuberculosis Intensified Case Finding among People Living with HIV in Western Kenya.

OBJECTIVE: To assess the performance of symptom-based screening for tuberculosis (TB), alone and with chest radiography among people living with HIV (PLHIV), including pregnant women, in Western Kenya. DESIGN: Prospective cohort study. METHODS: PLHIV from 15 randomly-selected HIV clinics were screened with three clinical algorithms [World Health Organization (WHO), Ministry of Health (MOH), and "Improving Diagnosis of TB in HIV-infected persons" (ID-TB/HIV) study], underwent chest radiography (unless pregnant), and provided two or more sputum specimens for smear microscopy, liquid culture, and Xpert MTB/RIF. Performance of clinical screening was compared to laboratory results, controlling for the complex design of the survey. RESULTS: Overall, 738 (85.6%) of 862 PLHIV enrolled were included in the analysis. Estimated TB prevalence was 11.2% (95% CI, 9.9-12.7). Sensitivity of the three screening algorithms was similar [WHO, 74.1% (95% CI, 64.1-82.2); MOH, 77.5% (95% CI, 68.6-84.5); and ID-TB/HIV, 72.5% (95% CI, 60.9-81.7)]. Sensitivity of the WHO algorithm was significantly lower among HIV-infected pregnant women [28.2% (95% CI, 14.9-46.7)] compared to non-pregnant women [78.3% (95% CI, 67.3-86.4)] and men [77.2% (95% CI, 68.3-84.2)]. Chest radiography increased WHO algorithm sensitivity and negative predictive value to 90.9% (95% CI, 86.4-93.9) and 96.1% (95% CI, 94.4-97.3), respectively, among asymptomatic men and non-pregnant women. CONCLUSIONS: Clinical screening missed approximately 25% of laboratory-confirmed TB cases among all PLHIV and more than 70% among HIV-infected pregnant women. National HIV programs should evaluate the feasibility of laboratory-based screening for TB, such as a single Xpert MTB/RIF test for all PLHIV, especially pregnant women, at enrollment in HIV services.

Comparative Yield of Different Diagnostic Tests for Tuberculosis among People Living with HIV in Western Kenya.

BACKGROUND: Diagnosis followed by effective treatment of tuberculosis (TB) reduces transmission and saves lives in persons living with HIV (PLHIV). Sputum smear microscopy is widely used for diagnosis, despite limited sensitivity in PLHIV. Evidence is needed to determine the optimal diagnostic approach for these patients. METHODS: From May 2011 through June 2012, we recruited PLHIV from 15 HIV treatment centers in western Kenya. We collected up to three sputum specimens for Ziehl-Neelsen (ZN) and fluorescence microscopy (FM), GeneXpert MTB/RIF (Xpert), and culture, regardless of symptoms. We calculated the incremental yield of each test, stratifying results by CD4 cell count and specimen type; data were analyzed to account for complex sampling. RESULTS: From 778 enrolled patients, we identified 88 (11.3%) laboratory-confirmed TB cases. Of the 74 cases who submitted 2 specimens for microscopy and Xpert testing, ZN microscopy identified 25 (33.6%); Xpert identified those plus an additional 18 (incremental yield = 24.4%). Xpert testing of spot specimens identified 48 (57.0%) of 84 cases; whereas Xpert testing of morning specimens identified 50 (66.0%) of 76 cases. Two Xpert tests detected 22/24 (92.0%) TB cases with CD4 counts <100 cells/µL and 30/45 (67.0%) of cases with CD4 counts ≥100 cells/µl. CONCLUSIONS: In PLHIV, Xpert substantially increased diagnostic yield compared to smear microscopy and had the highest yield when used to test morning specimens and specimens from PLHIV with CD4 count <100 cells/µL. TB programs unable to replace smear microscopy with Xpert for all symptomatic PLHIV should consider targeted replacement and using morning specimens.

The relationship between adherence to clinic appointments and year-one mortality for newly enrolled HIV infected patients at a regional referral hospital in Western Kenya, January 2011-December 2012.

This retrospective cohort analysis was conducted to describe the association between adherence to clinic appointments and mortality, one year after enrollment into HIV care. We examined appointment-adherence for newly enrolled patients between January 2011 and December 2012 at a regional referral hospital in western Kenya. The outcomes of interest were patient default, risk factors for repeat default, and year-one risk of death. Of 582 enrolled patients, 258 (44%) were defaulters. GEE revealed that once having been defaulters, patients were significantly more likely to repeatedly default (OR 1.4; 95% CI 1.12-1.77), especially the unemployed (OR 1.43; 95% CI 1.07-1.91), smokers (OR 2.22; 95% CI 1.31-3.76), and those with no known disclosure (OR 2.17; 95% CI 1.42-3.3). Nineteen patients (3%) died during the follow-up period. Cox proportional hazards revealed that the risk of death was significantly higher among defaulters (HR 3.12; 95% CI 1.2-8.0) and increased proportionally to the rate of patient default; HR was 4.05 (95% CI1.38-11.81) and 4.98 (95% CI 1.45-17.09) for a cumulative of 4-60 and ≥60 days elapsed between all scheduled and actual clinic appointment dates, respectively. Risk factors for repeat default suggest a need to deliver targeted adherence programs.

Menstrual Needs and Associations with Sexual and Reproductive Risks in Rural Kenyan Females: A Cross-Sectional Behavioral Survey Linked with HIV Prevalence.

BACKGROUND: Females in low and middle income countries (LMICs) have difficulty coping with menstrual needs, but few studies have examined the social or health implications of these needs. METHODS: Responses from 3418 menstruating females aged 13-29 years were extracted from an HIV and behavioral risks cross-sectional survey conducted in rural western Kenya. We examined sanitary products used, provision of products from sexual partners or from transactional sex, and demographic and sexual exposures. RESULTS: Overall, 75% of females reported using commercial pads and 25% used traditional materials such as cloth or items like paper or tissue, with 10% of girls <15 years old depending on makeshift items. Two-thirds of females with no education relied on traditional items. Having attended secondary school increased the odds of using commercial pads among married (adjusted odds ratios [AOR] 4.8, 95% confidence interval [CI] 3.25-7.12) and single females (AOR 2.17, 95% CI 1.04-4.55). Married females had lower odds of pad use if they reported early (<12 years of age) compared with later (≥18 years) sexual debut (64% vs. 78%, AOR 0.45, 95% CI 0.21-0.97). Two-thirds of pad users received them from sexual partners. Receipt was lower among married females if partners were violent (AOR 0.67, 95% CI 0.53-0.85). Receipt among single females was higher if they had two or more sexual partners in the past year (AOR 2.11, 95% CI 1.04-4.29). Prevalence of engaging in sex for money to buy pads was low (1.3%); however, 10% of 15-year-olds reported this, with girls ≤15 having significantly higher odds compared with females over 15 (AOR 2.84, 95% CI 0.89-9.11). The odds of having transactional sex for pads was higher among females having two or more partners in the past 12 months (AOR 4.86, 95% CI 2.06-11.43). CONCLUSIONS: Menstrual needs of impoverished females in rural LMICs settings likely leads to increased physical and sexual harms. Studies are required to strengthen knowledge and to evaluate interventions to reduce these harms.